“How Can I Tell If the ADHD Medication is Working?” Treatment Troubleshooting Guide
How do you know whether an ADHD medication is doing its job? Reliable tracking means recognizing symptom changes and working with your clinician to fine-tune dosing or to investigate other medications until an ideal combination is reached for your individual needs.
It’s a common and understandable question, especially for those newly diagnosed with attention deficit hyperactivity disorder (ADHD or ADD). Gauging whether a medication is working as well as it should, or whether it’s the right medication at all, requires consistent self-appraisal and ongoing communication with your clinician regarding symptom control — or lack thereof. It also requires patience as the clinician works to potentially adjust or switch medications before settling on the right combination for you.
How to Tell If Your ADHD Medication is Working: Targets and Adjustments
The following two questions will help you and your clinician determine whether the current ADHD medication and/or dose is ideal and effective:
1. What are you expecting from ADHD medication?
Any medication should work to decrease ADHD symptoms at the lowest optimal dose. To know for sure if the medicine is accomplishing this, first work with your clinician to come up with a list of four or five target symptoms that can actually be measured before starting on medication.
Choose target symptoms that are already known to respond well to medication. They include (but are not limited to):
- Procrastination, difficulty getting started on boring tasks
- Restlessness, fidgeting
- Mood lability
- Emotional overreactions
- Impulsivity, acting or speaking without thinking
- Temper flashes and outbursts
- Poor reading speed, comprehension, and retention
- Difficult to stick with boring activities to the pay-off
- Scattered, misplace things
ADHD symptoms that are known to not be influenced as much by medication include:
- Sense of time
- Argumentativeness; disobeying rules
2. Are you seeing improvement in your target ADHD symptoms?
Your doctor will likely start you on a stimulant – the first line treatment for ADHD – at a low dose, and increase it periodically in the smallest increments manufactured. Stimulant medications are completely effective the first time you take them as soon as they reach the brain. You will see all of the benefits and all of the side effects of that medication and dose right from the very first day.
This means that late adolescents and adults can adjust their dose every day if they want to. Children, however, who lack self-perception and lack the words to describe what they are experiencing, need more time at each dosage level in order to accurately assess the effects of the ADHD medication. Elementary-aged children should see their doctors regarding a dose change no more often than every 5-7 days so that the observations of both parents and another observer (like a school teacher) can be incorporated in the decision to raise or lower the dose.
The patient can keep increasing the medications so long as each time they do, they get a clear improvement in all of their target symptoms and only minimal side effects. If the patient increases the dose and does not see further improvement, then the previous lower dose is that person’s “sweet spot” dose. It is the lowest dose that provides optimal level of benefits without significant side effects. But how can you tell if you’re improving?
How to Tell If Your ADHD Medication is Working: Scales and Tests
On a Scale of 1 to 10…
Without overthinking it, rank or score your current ADHD medication on a scale of 1 to 10: 1 being just awful – nothing but side effects – and 10 being the best you can imagine a medication ever working.
Many clinicians ask some version of this question to patients and require other self-appraisals to determine how well the medication is reducing symptoms. Generally, they’re looking for scores of 8 through 10. Nine is a very good response to medication. For most people, the lowest acceptable score is a 7.
ADHD stimulant medications are not subtle – they are some of the most effective medications in all of medicine. Most clinicians have found that people who respond with a 6 or lower, therefore, can do much better on a different medication or a difference dose. So, if you think that you have fine-tuned this particular medication but you are not experiencing a life-changing level of improvement, continue to work with your clinician to find the right medication and dose for you.
Standardized Medication Scales
There is only one scale that is research validated to be able to monitor progress in medication response trials – the Conner Global Index Scale, designed for children ages 3 to 17. It is filled out by the teacher and a parent, which asks for ratings across several areas including restless-impulsive behaviors and emotional lability. The scale is administered prior to medication so as to come up with a baseline for comparison while a child is on medication.
Some clinicians test symptom improvement by conducting computerized continuous performance testing (for example, the TOVA, the Quadrant, the Conner’s etc.). This is a single measurement in time of two major areas of impairment from any cause of 1) vigilance, attention, distractibility, and 2) impulse control. As with standardized scales, testing has to start prior to treatment to create a baseline to which subsequent tests on various doses of medication can be compared. The cost is about $100 per test. However, it’s worth noting that some individuals who effectively hyperfocus can achieve high or “normal” scores on these tests on or off medication. In such cases these tests are not useful or informative.
No matter the method, your doctor will work to arrive at an optimal dose by increasing the dosage until it no longer results in further improvement (or until worsened symptoms and side effects appear) – the previous dose, therefore, was the lowest to achieve optimal performance.
How to Tell If ADHD Medication is Working: Treatment Troubleshooting
Not everyone responds well to stimulant medications. In fact, about 15 percent of individuals who have tried both of the usual stimulant class medications (methylphenidate and amphetamine) either do not see any benefit or cannot tolerate the side effects even at the lowest doses.
If all signs indicate that a given stimulant medication is not working, the treatment troubleshooting process typically goes like this:
- Check the diagnosis. Evaluation and diagnosis mistakes do happen. Go back to the drawing board to be sure that you have the right diagnosis and all of the diagnoses that are present.
- Check absorption. If a patient shows no benefits and no side effects, this may indicate that the medication isn’t being properly absorbed. It’s best to avoid organic acids (citric acid or ascorbic acid, like fruit juices, soft drinks, daily multivitamins) about one hour before and after taking the dose. (Note: Vyvanse and Daytrana are the only stimulants not affected by organic acid intake). Transdermal delivery (via a skin patch) can also be tested.
- Try non-stimulants. Non-stimulant medications (clonidine, guanfacine) are the second-line treatment for ADHD. While research shows that stimulants are more effective, many individuals can see positive responses from non-stimulants. The next most effective class of medications are the alpha agonist drugs clonidine (Kapvay) and guanfacine (Intuniv). The non-stimulants are most effective with symptoms of hyperactivity and impulsiveness (i.e. excess energy, insomnia, multiple simultaneous thoughts).
- Try atomoxetine. Strattera is a good third line medication. It is a noradrenaline reuptake inhibitor, and so it has a sizable response rate (about 50%), and can be added to other medications. Unfortunately, Strattera also has a high side effect burden especially in adults.
- Consider methamphetamine. Sold under the brand name Desoxyn, this drug is approved for ADHD treatment. And yet, it still carries negative connotations among many patients and clinicians. Many individuals with ADHD, however, who did not get a good response from any of the alternatives above will get a very good response to methamphetamine with few side effects and at very low doses. The negative connotations to just the name of “methamphetamine” makes it extremely difficult to find a patient willing to take it, a clinician willing to prescribe it, and a pharmacy willing to carry it in stack.
How to Tell If ADHD Medication is Working: Next Steps
- Download: The Ultimate Guide to ADHD Medication
- Read: How Does ADHD Medication Work? With Lots of Monitoring
- Learn: 10 Things Your Doctor May Not Have Told You About ADHD Medications
The content for this article was derived from the ADDitude Expert Webinar “Optimizing ADHD Medication: Strategies for Achieving Better Symptom Management” by William Dodson, M.D. (available as ADDitude ADHD Experts Podcast episode #277), which was broadcast live on November 13, 2019.
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